On appetite and its loss

Mirtazapine versus megestrol acetate in treatment of anorexia-cachexia in advanced cancer patients: a randomized, double-blind trial

OBJECTIVE

Cancer-related anorexia-cachexia comprises one of the most common syndromes of advanced cancer patients. The management of cancer-related anorexia-cachexia is a great challenge in clinical practice. There are no definite practice guidelines yet for the prevention and treatment of cancer-related anorexia-cachexia. This study is considered to find out whether there is any role of mirtazapine in the improvement of anorexia in cancer patients.

METHODS

A total of 80 cancer-anorexia patients were enrolled. Patients in the trial arm received the standard chemotherapy medication plus one tablet of mirtazapine 15 mg daily at night orally for 8 weeks starting from the day of an initial assessment. The control arm received the standard chemotherapy medication plus one tablet of megestrol acetate 160 mg daily orally for 8 weeks starting from the day of an initial assessment. Each patient was assessed by validated versions of Functional Assessment of Anorexia/Cachexia Therapy Anorexia/Cachexia Sub Scale v 4 questionnaires.

RESULTS

After 4 and 8 weeks each patient was evaluated again using the Functional Assessment of Anorexia/Cachexia Therapy Anorexia/Cachexia Sub Scale tool. The quality of life of each patient was assessed by European Organization for Research and Treatment QLQ-C30 v 3.0. After 4 to 8 weeks of treatment, the Functional Assessment of Anorexia/Cachexia Therapy Anorexia/Cachexia Sub Scale score in cancer anorexia patients in the mirtazapine improved anorexia significantly. However, the improvement after 4 to 8 weeks was not statistically significant when it was compared with the megestrol acetate (P > 0.05).

CONCLUSIONS

Therefore, the findings of this study reveal that mirtazapine might be a potential alternative to megestrol acetate, as it has shown potential efficacy as like as megestrol acetate.

Quality of Life and Fatigue in Hodgkin's Lymphoma Patients

Aims and background

Quality of life and survival of patients with malignant diseases are improving thanks to the development in diagnostics and therapy.

Methods

We determined the quality of life and frequency and severity of fatigue with an EORTC QLQ-C30 questionnaire in 168 Hodgkin's lymphoma patients (85 women, 83 men). We scored all functional and symptom scales in cured patients (who were in complete remission for at least 10 years; mean period of survival after the treatment(s) was 16.61 years) and in those who suffered from late complications.

Results

The global health status score (QL2) was significantly lower in patients who had late complications (mean QL2, 45.53) than in patients with no complications (mean QL2, 67.57, P <0.001) and in cured patients (mean QL2, 52.5) than in those who were not disease free 10 years after the treatment or who were treated actively (mean QL2, 67.48, P <0.001). We found that fatigue level (FA) was significantly higher in patients who had been treated more than 20 years before (FA score, 53.37) than in those who were undergoing treatment (FA score, 29.35, P = 0.03). A significantly higher FA score (FA, 48.72) was observed in patients who suffered from late complications of the treatment than in those who had no complications (FA, 31.88; P = 0.001). More co-morbidity can cause higher fatigue scores than observed in these groups of Hodgkin's lymphoma patients.

Conclusions

Fatigue is more frequent than we think, and it has a strong effect on quality of life, so its early recognition and treatment is important and needs multidisciplinary cooperation.

Does nutrition support have a role in managing cancer cachexia?

PURPOSE OF REVIEW

Cachexia is a negative prognostic factor in cancer patients. The pathogenesis is related to a variable combination of reduced food intake and metabolic changes. However, whether nutritional support may contribute to effectively prevent and treat cachexia remains a debated issue.

RECENT FINDINGS

Consistent evidence demonstrates that anabolic windows of opportunity occur during the clinical trajectory of cancer patients. Also, the use of specific nutrients, namely omega-3 fatty acids, may enhance the efficacy of nutritional support when tumor-driven inflammatory response is high. Of greater interest, it is now becoming clearer that the use of nutritional support at key time points in the clinical journey of cancer patients (i.e., perioperative period) may extend its clinical benefits beyond those on nutritional status.

SUMMARY

Nutritional support plays a role in managing cancer cachexia, when it is timely delivered, when it provides adequate amounts of calories and proteins, and when it is part of a concurrent palliative care approach. Specific nutrients, that is, omega-3 fatty acids, may help in those cancer patients with high-inflammatory response, and may also contribute to positively influence long-term clinical outcomes.

Psychological Distress and Resilience in Women Diagnosed with Breast Cancer in Greece

Background:

Breast cancer is the most frequent type of cancer among women worldwide, especially in developed countries. To be diagnosed with breast cancer and undergo cancer treatment can be a very stressful event. It is estimated that one-third of cancer patients are dealing with psychological problems, such as anxiety and depression and resilience is a way of coping and overcome life stressors such cancer diagnosis.

Purpose:

The purpose of this study was to examine resilience in women diagnosed with breast cancer and its association with depression and anxiety.

Methods:

A cross-sectional study was conducted, 144 women diagnosed with breast cancer answered a questionnaire consisted of four parts: Sociodemographic data, the Patient Health Questionnaire Two-Item Depression Scale, the Generalized Anxiety Disorder Questionnaire and the Connor-Davidson Resilience Scale 25.

Results:

The majority of the sample belongs to age group 51- 60 years, with the mean age of 53.5 SD±11.7 years. The 59.5% of patients were residents of an urban area, 56.8% were married and 36.5% has 2 children. The mean value of CD-RISC25 was 65.3 SD±17.9, meaning a moderate resilience of cancer patients. The 54.5% of respondents indicated a depressed mood. The anxiety severity measured with the GAD-2, where the mean was 2.1 and 46.8% of patients suffered from high anxiety.

Conclusions:

According to our results, resilience can negative influence depressive symptomatology. Moreover, lower levels of depression can lead to fewer anxiety symptoms.

Hypnosis for Symptom Control in Cancer Patients at the End-of-Life: A Systematic Review

Hypnosis has been shown to alleviate symptoms and side effects of cancer and its treatment. However, less is known about the use of hypnosis at the end of life in individuals with cancer. Our goal was to systematically review the literature on the use of hypnosis to manage the most common symptoms of end-of-life cancer patients: fatigue, sleep disturbances, pain, appetite loss, and dyspnea. EMBASE, MEDLINE, COCHRANE, PsychINFO, and SCOPUS databases were searched from inception through November 7, 2016. No studies met the inclusion criteria. It appears that hypnosis has never been rigorously tested as a means to ameliorate the most common symptoms in individuals with cancer at the end of their lives. This finding is troubling, as it strongly implies that a population most in need has been largely neglected. However, a clear future research direction is revealed that may have significant clinical impact.

Chinese Herbal Medicine for Symptom Management in Cancer Palliative Care: Systematic Review And Meta-analysis

Use of Chinese herbal medicines (CHM) in symptom management for cancer palliative care is very common in Chinese populations but clinical evidence on their effectiveness is yet to be synthesized. To conduct a systematic review with meta-analysis to summarize results from CHM randomized controlled trials (RCTs) focusing on symptoms that are undertreated in conventional cancer palliative care.Five international and 3 Chinese databases were searched. RCTs evaluating CHM, either in combination with conventional treatments or used alone, in managing cancer-related symptoms were considered eligible. Effectiveness was quantified by using weighted mean difference (WMD) using random effect model meta-analysis. Fourteen RCTs were included. Compared with conventional intervention alone, meta-analysis showed that combined CHM and conventional treatment significantly reduced pain (3 studies, pooled WMD: -0.90, 95% CI: -1.69 to -0.11). Six trials comparing CHM with conventional medications demonstrated similar effect in reducing constipation. One RCT showed significant positive effect of CHM plus chemotherapy for managing fatigue, but not in the remaining 3 RCTs. The additional use of CHM to chemotherapy does not improve anorexia when compared to chemotherapy alone, but the result was concluded from 2 small trials only. Adverse events were infrequent and mild. CHM may be considered as an add-on to conventional care in the management of pain in cancer patients. CHM could also be considered as an alternative to conventional care for reducing constipation. Evidence on the use of CHM for treating anorexia and fatigue in cancer patients is uncertain, warranting further research.

Assessing the Symptoms of Cancer Using Patient-Reported Outcomes (ASCPRO): searching for standards

The U.S. Food and Drug Administration (FDA) 2006 draft guidance on "Patient-Reported Outcome Measures: Use in Medical Product Development to Support Labeling Claims" has engendered wide discussion about patient-reported outcome (PRO) domains that should be endpoints in clinical trials. Reducing the severity and impact of symptoms is a natural intervention endpoint for cancer, a condition associated with considerable symptom burden. Because symptoms are best described by patients who have them, including PROs as measures of treatment effectiveness or the differences among treatments provides essential information about the efficacy and toxicity of a treatment and its effects on function. The FDA guidance provides a framework for addressing such issues as clinical significance, study design, and statistical methods as they relate to applications for labeling claims; however, no set of recommended approaches for assessing specific symptoms by patient report in clinical trials exists, other than for pain. Accordingly, an interdisciplinary workgroup, Assessing the Symptoms of Cancer using Patient-Reported Outcomes (ASCPRO), has been formed to generate evidence-based recommendations for the assessment of patient-reported cancer-related symptoms and the use of that information to facilitate clinical research and decision making. ASCPRO is among the first working groups to focus primarily on nonpain symptoms, including fatigue, sleep disturbance, appetite loss, depression, cognitive impairment, and shortness of breath. ASCPRO members are stakeholders in optimal symptom assessment, including patient advocates, academics, clinicians, those who pay for symptom control and monitor quality of care, and those who produce products that palliate cancer-related symptoms but that may also engender treatment-related symptoms.

North Central Cancer Treatment Group--achievements and perspectives

The North Central Cancer Treatment Group (NCCTG) was founded in 1977 as a regional cooperative group to allow cancer patients in the upper Midwest of the United States to gain access to clinical trials in oncology by establishing a network of community oncology practices with one academic research base, the Mayo Clinic. Since then, the NCCTG has grown into an international cooperative group with 43 members in 33 US states and Canada. This article details 30 years of achievements of the NCCTG, including important scientific contributions from disease-specific and treatment modality committees, the cancer control program, patient-reported outcomes and quality-of-life research, and biostatisticians that support the NCCTG's specific aims: to improve the duration and quality of life of cancer patients, to enhance our understanding of the biological consequences of cancer and its treatment, and to improve methods for clinical trial conduct.

Symptom burden: multiple symptoms and their impact as patient-reported outcomes

Cancer and its treatment produce multiple symptoms that significantly distress patients and impair function. Symptoms caused by treatment may delay treatment or lead to premature treatment termination, and residual treatment-related symptoms often complicate posttreatment rehabilitation. When treatment is no longer possible, symptom control becomes the focus of cancer care. Patient ratings of symptom severity and impact are important patient-reported outcomes (PROs) in cancer clinical trials and comprise a subset of a larger domain of PROs generally referred to as health-related quality of life (HRQOL). Symptoms rarely occur in isolation; rather, there is now ample evidence that symptoms frequently occur in clusters. The impact of these multiple symptoms upon the patient can be described as "symptom burden," a concept that encompasses both the severity of the symptoms and the patient's perception of the impact of the symptoms. The distress caused by symptoms is a subject of much investigation, and several validated measures of the severity and impact of multiple symptoms are now available. Symptom measures are generally brief, thereby reducing respondent burden, and can be administered repeatedly during a trial to give a relatively fine-grained picture of the patient's status across time. In many instances, information on trial-related changes in symptom burden, or comparison of symptom burden between arms in a clinical trial, may provide sufficient self-report data for clinical trial consumers (patients, clinicians, and regulators) to make treatment choices or to evaluate new therapies, without measuring other HRQOL domains.

The management of anorexia by patients with advanced cancer: a critical review of the literature

This report presents the results of a critical review of the literature on the experience of anorexia (loss of appetite) by patients with advanced cancer. Although several studies have investigated this experience, the adaptive strategies used by patients to compensate for appetite loss remain poorly elucidated. Based on the small body of extant research, it was concluded that, in many instances, a gap exists between the ability of patients and caregivers to come to terms and deal realistically with the emotional and social consequences of patient anorexia. Patients generally appear to suffer greater discord as a result of this disparity, than from the direct psychological impact of anorexia. A greater understanding of the management of anorexia by patients is essential for the development of dietary and psychosocial interventions that would aid both patients and caregivers to cope with this common symptom.

Treatment of unintentional weight loss in patients with cancer

Malnutrition from anorexia and reduced nutrient intake is common in patients with cancer. Abnormalities in gastrointestinal function caused by the tumor or treatment of the tumor may be direct causes for nutrition challenges. However, other patients may present with cancer cachexia, a wasting syndrome characterized by weight loss, anorexia, early satiety, progressive debilitation, and malnutrition that results in a greater risk of organ dysfunction and death. Changes in host metabolism and energy expenditure are thought to contribute to the development of cachexia, although this relationship is not clear. There is evidence that the etiology of these metabolic changes may be mediated by a neurohormonal response stimulated by the tumor. Because a single cause for these metabolic abnormalities has not been identified, several approaches to treatment of cancer cachexia have been reported. After correction of any underlying gastrointestinal abnormalities, single nutrients or other pharmacologic agents have been used in an attempt to favorably affect appetite or counter metabolic abnormalities that cause inefficient nutrient use. A variety of agents have been studied for their positive effects on appetite, including progestational agents, glucocorticoids, cannabinoids, cyproheptadine, olanzapine, and mirtazapine. Other agents have been investigated for their anti-inflammatory properties, including thalidomide, pentoxyphylline, melatonin, and omega-3 fatty acids. Anabolic agents such as testosterone derivatives have been investigated as well. The decision to treat symptoms of cancer cachexia should be based on the patient's desires and current medical condition. Choice of the most appropriate agent to treat unintentional weight loss in patients with cancer should include consideration of effects on appetite, weight, quality of life, and risk of adverse effects according to current evidence-based medicine, and cost and availability of the agent.

The cancer anorexia/weight loss syndrome: therapeutic challenges

The cancer anorexia/weight loss syndrome is characterized by loss of weight, loss of appetite, overall decline in quality of life, and shortened survival in patients with advanced incurable cancer. It is highly prevalent. To date, treatment options that have been firmly established with good scientific evidence are limited to progestational agents and corticosteroids, both of which have been demonstrated to improve appetite but have otherwise failed to have a favorable impact on some of the other aspects of this syndrome. As the mechanisms behind this syndrome are further elucidated, more effective therapeutic strategies will likely emerge.

Fish oil, lean tissue, and cancer: is there a role for eicosapentaenoic acid in treating the cancer anorexia/weight loss syndrome?

Eicosapentaenoic acid is an omega-3 fatty acid, a group of fatty acids characterized by a double bond that sits three carbons down from the n terminal of the molecule. Derived from dark, rich fish, eicosapentaenoic acid has received increasing attention as a therapy for the cancer anorexia/weight loss syndrome. Multiple studies, including laboratory and preliminary clinical studies suggest this fish oil derivative may benefit cancer patients. Recently, however, three large comparative studies suggest that eicosapentaenoic acid is relatively ineffective for treating this syndrome. In view of these recent results, the goals of this review are as follows: (1) to provide background on the mandate for further study of the cancer-associated anorexia/weight loss syndrome; (2) to review the preliminary data that have suggested that eicosapentaenoic acid is a promising agent for treating this syndrome; (3) to review the methodology and findings of the more recent, definitive clinical trials; (4) to discuss and speculate on why the earlier positive findings drew conclusions that are discrepant from the results of more recent comparative clinical studies.

Megestrol acetate for the treatment of anorexia-cachexia syndrome

BACKGROUND

Megestrol acetate (MA) is currently used to improve appetite and to increase weight in cancer-associated anorexia. In 1993 MA was approved by the USA's Federal Drug Administration for the treatment of anorexia, cachexia, or unexplained weight loss in patients with AIDS. The mechanism by which MA increases appetite is unknown, and its effectiveness for anorexia and cachexia in neoplastic and AIDS patients is under investigation.

OBJECTIVES

To evaluate the efficacy, effectiveness and safety of MA in palliating anorexia-cachexia syndrome in patients with cancer, AIDS and other underlying pathologies.

SEARCH STRATEGY

Studies were sought thorough an extensive search of the electronic databases, journals, reference lists, contact with investigators and other search strategies outlined in the methods. The most recent search was carried out on October 2002.

SELECTION CRITERIA

Studies were included in the review if they assessed megestrol acetate compared to placebo or other drug treatments in randomized controlled trials of patients with a clinical diagnosis of anorexia-cachexia related to cancer, AIDS or another underlying pathology.

DATA COLLECTION AND ANALYSIS

Data extraction was conducted by two independent authors, and methodological quality evaluated. Quantitative analyses were performed using appetite and quality of life as a dichotomous variable, and weight gain was analysed as continuous and dichotomous variables. Studies with more than 50% of patients lost to follow-up were excluded from the analysis.

MAIN RESULTS

Thirty trials met the inclusion criteria (4123 patients). Twenty-one trials compared MA at different doses with placebo; four compared different doses of MA versus other drugs; two compared MA with other drugs and placebo; and three compared different doses of MA. For all patient conditions, meta-analysis showed a benefit of MA compared with placebo, particularly with regard to appetite improvement and weight gain in cancer patients. Analysing quality of life, clinical and statistical heterogeneity was found and discussed. There was insufficient information to define the optimal dose of MA.

AUTHORS' CONCLUSIONS

This review demonstrates that MA improves appetite and weight gain in patients with cancer. No overall conclusion about quality of life (QOL) could be drawn due to heterogeneity. The small number of patients, methodological shortcomings and poor reporting have not allowed us to recommend megestrol acetate in AIDS patients or with other underlying pathologies.

Quality-of-life assessment in the symptom management trials of the National Cancer Institute-supported Community Clinical Oncology Program

PURPOSE

To examine how quality of life (QOL) is prospectively conceptualized, defined, and measured in the symptom management clinical trials supported by the National Cancer Institute Community Clinical Oncology Program (CCOP).

METHODS

All QOL research objectives, rationales, assessment instruments, symptoms treated, and types of interventions from the CCOP symptom management portfolio of clinical trials were extracted and analyzed.

RESULTS

QOL assessments were proposed in 68 (52%) of the 130 total CCOP symptom management trials initiated since 1987. A total of 22 global QOL instruments were identified. Both the frequency of symptom management trials and the frequency of QOL assessment have increased significantly over time. The Functional Assessment of Cancer Therapy and Uniscale instruments were the most widely used QOL instruments, included in 55% of trials assessing QOL. The conceptual framework for QOL inclusion was limited to univariate relationships between symptom relief and global improvements in QOL. No consistent associations were found between QOL assessment and either the symptoms targeted or types of interventions.

CONCLUSION

To advance the state of the science, research protocols need to provide more explicit rationales for assessing QOL in symptom management trials and for the selection of the QOL instrument(s) to be used. Conceptual frameworks that specify the hypothesized links between the specific symptom(s) being managed, interactions with other symptoms, different domains of QOL, and global QOL also need to be more precisely described. Methodologic and conceptual advances in QOL symptom management trials are critical to fulfill the promise of alleviating suffering and improving the QOL of cancer patients.

Outcome research in palliative care: could it represent a new dimension of clinical research or clinical practice?

Outcome research is a new dimension of clinical research, and all fields of clinical medicine are involved in this kind of analysis. Overall survival and quality of life are the main outcomes identified in clinical oncology. The former must be the main outcome whenever possible; the latter has to be the main outcome when an improvement of overall survival cannot be expected. It follows that quality of life is the main outcome of palliative care, in which the patient instead of the disease represents the target of the clinical approach. In our critical paper, we review the meaning of clinical outcomes in palliative care, classifying the outcomes as main and surrogate outcomes, and the results of the trials as indexes of activity and efficacy of a treatment. We also review the main randomized clinical trials on the treatment of cancer cachexia, trying to define the role of the treatments in cachexia-related symptom control and quality of life improvement. Strictly related to outcome analysis is the dimension of pharmacoeconomic evaluation. The models of the different designs of pharmacoeconomic analysis are revisited in an attempt to conjugate the pharmacoeconomic evaluation with the particular dimension of palliative care.

Phase III, randomized, double-blind study of epoetin alfa compared with placebo in anemic patients receiving chemotherapy

PURPOSE

To determine whether weekly epoetin alfa could improve hemoglobin (HgB) levels, reduce RBC transfusions, and improve quality of life (QOL) in patients with advanced cancer and with anemia after receiving myelosuppressive chemotherapy.

PATIENTS AND METHODS

This double-blind, placebo-controlled study randomly assigned patients to placebo or epoetin alfa (Ortho Biotech, Bridgewater, NJ) 40,000 U subcutaneous weekly for 16 weeks. QOL, HgB, and RBC transfusions were measured pretreatment and monthly.

RESULTS

The study accrued 344 patients; 330 were assessable for efficacy and 305 were assessable for QOL. Placebo-treated patients had a mean increase in HgB of 0.9 g/dL (range, -3.8 to +5.3) compared with 2.8 g/dL (range, -2.2 to +7.5) for epoetin-treated patients (P < .0001). During the study, 31.7% of placebo-treated patients achieved a > or = 2 g/dL HgB increase compared with 72.7% of epoetin-treated patients (P < .0001). The incidence of RBC transfusion for placebo and epoetin treatment arms was 39.6% and 25.3% (P = .005), respectively. The placebo group received 256 units of RBCs compared with 127 units in the epoetin group (P < .0001). The incidence of toxicity in the groups was similar. Changes in the average QOL scores from baseline to the end of the study were similar in the two groups (P = not significant). The HgB responders (irrespective of treatment arm) had a mean change in Functional Assessment of Cancer Therapy (FACT) fatigue score from a baseline of +5.1 compared with -2.1 for the nonresponders (P = .006).

CONCLUSION

Epoetin alfa significantly improved HgB and reduced transfusions in this patient population. These results support the use of weekly epoetin alfa as an ameliorative agent for cancer-related anemia.

Appetite and Cancer-Associated Anorexia: A Review

Appetite is governed by peripheral hormones and central neurotransmitters that act on the arcuate nucleus of the hypothalamus and nucleus tactus solitarius of the brainstem. Cancer anorexia appears to be the result of an imbalance between neuropeptide-Y and pro-opiomelanocortin signals favoring pro-opiomelanocortin. Many of the appetite stimulants redress this imbalance. Most of our understanding of appetite neurophysiology and tumor-associated anorexia is derived from animals and has not been verified in humans. There have been few clinical trials and very little translational research on anorexia despite its prevalence in cancer.

Molecular-based therapeutic approaches in treatment of anorexia of aging and cancer cachexia

Loss of appetite, or anorexia, has profound implications for older persons, altering social interactions, reducing quality of life, and leading to weight loss with grave health consequences. Two conditions associated with anorexia considered in this article are the multidetermined anorexia of aging and the wasting syndrome termed cachexia induced by cancer. Nutritional interventions may have some benefit in the former, but are of limited value in the latter. Emerging studies at the molecular level relating to appetite regulation and energy balance may offer new approaches to arrest progressive weight loss in the anorexia of aging and cancer cachexia.

[Megestrol acetate: a systematic review usefulness about the weight gain in neoplastic patients with cachexia]

BACKGROUND

The clinical efficacy of megestrol acetate in the treatment of cachexia in cancer patients has not been clearly demonstrated. A systematic review and meta-analysis have been performed to ascertain its effectiveness on weight gain in patients with cancer-associated cachexia.

MATERIAL AND METHOD

A systematic review of randomized clinical trials comparing megestrol acetate with placebo in cancer patients was performed. The outcome measure used was weight gain expressed as the difference in weight at the outset compared with that at the end of treatment. Trials analyzed were those that allowed for this calculation, or those whose authors provided information for the above calculation.

RESULTS

Patients treated with placebo had an average weight loss of 1.090 kg (CI 95%, 1.620 to 0.561), whereas patients treated with megestrol acetate gained an average 0.423 kg (CI 95%, 0.078-0.769). A weight gain of 0.448 kg (CI 95%, 0.021-0.874) was observed with acetate megestrol doses # 240 mg. No statistically significant effect was observed when using higher doses: 0.358 kg (CI 95%, 0.135-0.85).

CONCLUSIONS

Megestrol acetate doses equal to or lower than 240 mg/day lead to slight weight gain in patients with cancer-associated cachexia. The majority of studies have a low methodological quality. Further, well-designed studies comparing megestrol acetate with placebo are warranted.

Cachexia in patients with advanced cancer

Cancer cachexia generally is considered to be the end stage in the progression of nutritional deterioration and wasting of malignancy (Ottery, 1995). In patients with advanced cancer, this condition is very common and decreases quality of life, as well as survival (Fearon et al., 2001; Ottery; Smith & Souba, 2001; Whitman, 2000). However, if early diagnosis and intervention can control cachexia, the potential exists to greatly improve a patient's quality of life and prolong survival. Because metabolic alterations inhibit the effective use of conventional nutritional support, anti-inflammatory agents or fish oil are possible options. Orexigenic agents may be prescribed if patients wish to improve oral intake. Steroids and progestational agents may be used to attempt to improve mood and appetite. Nutrition affects symptoms that need to be managed effectively. Nurses should work aggressively to correct factors that contribute to decreased food intake (e.g., nausea, pain) and correct factors that worsen debility (e.g., anemia). Information must be presented so that informed choices can be made and realistic eating goals set. An interdisciplinary approach that involves the nurse, physician, dietician, and possibly social worker or case manager, as well as the patient and family, is necessary to identify nutritional alterations, assess specific needs, and plan individual interventions. Whitman (2000) stated that counseling is the most effective and least expensive intervention. It may be conducted by any member of the healthcare team and should be combined with other interventions. Palliation of cachexia in patients with advanced cancer is a challenge for nurses. Hopefully, early and judicious use of these interventions may decrease the significant morbidity and mortality that result from cancer cachexia.

Update on anorexia and cachexia

Declining physical, emotional, and social function as a result of anorexia and cachexia are considerable contributors to discomfort for cancer patients and their families, and they impair the patient's ability to express optimal physical and psychosocial potential as long as possible. This decline no longer has to be accepted as an indispensable sequel to advanced cancer, just as pain is no longer considered to be unavoidable. A routine screening for anorexia and cachexia and associated symptoms is necessary, as is a careful, comprehensive assessment, because the condition is not always obvious. Decisions about anorexia and cachexia treatment are guided by prioritizing the different, concurrent physical, psychosocial, and existential problems and by considering the natural course of the cancer and the effects of antineoplastic therapies. Reversible causes for anorexia and cachexia need to be identified and treated, if appropriate. Nutritional interventions are often indicated; patients with a predominant starvation component and without inflammation may profit the most. New pharmacologic therapies for primary anorexia and cachexia syndrome are expected to enter clinical practice soon; however, until then, treatment with corticosteroids, progestins, or prokinetics may be indicated for some patients. To understand a multicausal syndrome, multimodal and interdisciplinary therapy is required. Specialist palliative care services can be helpful to provide, hand-in-hand with the disease specialists [172], assessment and management of psychophysical symptoms and sociospiritual needs of patients during the course of the illness and at the end of life [173]. Research efforts aim to better characterize subgroups of patients suffering from secondary causes of anorexia and cachexia and to elucidate the mechanisms involved in the primary anorexia and cachexia syndrome. Increasingly individualized treatments are expected with combination treatments that involve different mechanisms including nutrition.

Supportive use of megestrol acetate (Megace) with head/neck and lung cancer patients receiving radiation therapy

PURPOSE

The purpose of this study was to measure the effect of megestrol acetate (MA) on weight loss and quality of life (QOL) in patients with cancer of the lung or head and neck undergoing curative radiation therapy.

METHODS AND MATERIALS

This was a Phase III, placebo-controlled, double-blind randomized study. Patients received either 800 mg/day of MA (20 milliliters po qAM) or placebo over a 12-week period. Patients received radiation of the head and neck or thorax using a dose of at least 50 Gy, either alone or with chemotherapy. Weight was assessed weekly, whereas QOL was assessed at baseline and at 4, 8, and 12 weeks.

RESULTS

Patient characteristics on the MA arm (16 lung, 12 head/neck; mean age: 60 years) were similar to those on the placebo arm (17 lung, 11 head/neck; mean age: 65.8 years). Patients in the MA group had a mean weight loss over 12 weeks of 2.7 pounds, whereas the placebo group had a mean weight loss of 10.6 pounds. There was a significant time by treatment interaction (p = 0.001), with the difference in weight between treatment groups being most pronounced after 6 weeks. Although overall QOL was similar in both arms of the study, several QOL subscale items did differ significantly. Compared to the placebo-treated patients, head-and-neck cancer patients in the MA arm reported the ability to eat as much as they liked (p = 0.02 at 12 weeks), and lung cancer patients in the MA arm reported significantly better appetite at 4 weeks (p = 0.03) and 8 weeks (p = 0.001).

CONCLUSION

MA used prophylactically is useful as an appetite stimulant; it can help patients maintain weight over the course of curative radiotherapy of the head and neck or lung and can improve specific aspects of QOL.

Dronabinol versus megestrol acetate versus combination therapy for cancer-associated anorexia: a North Central Cancer Treatment Group study

PURPOSE

To determine whether dronabinol administered alone or with megestrol acetate was more, less, or equal in efficacy to single-agent megestrol acetate for palliating cancer-associated anorexia.

PATIENTS AND METHODS

Four hundred sixty-nine assessable advanced cancer patients were randomized to (1) oral megestrol acetate 800 mg/d liquid suspension plus placebo, (2) oral dronabinol 2.5 mg twice a day plus placebo, or (3) both agents. Eligible patients acknowledged that loss of appetite or weight was a problem and reported the loss of 5 pounds or more during 2 months and/or a daily intake of less than 20 calories/kg of body weight.

RESULTS

Groups were comparable at baseline in age, sex, tumor type, weight loss, and performance status. A greater percentage of megestrol acetate-treated patients reported appetite improvement and weight gain compared with dronabinol-treated patients: 75% versus 49% (P =.0001) for appetite and 11% versus 3% (P =.02) for > or = 10% baseline weight gain. Combination treatment resulted in no significant differences in appetite or weight compared with megestrol acetate alone. The Functional Assessment of Anorexia/Cachexia Therapy questionnaire, which emphasizes anorexia-related questions, demonstrated an improvement in quality of life (QOL) among megestrol acetate-treated and combination-treated patients. The single-item Uniscale, a global QOL instrument, found comparable scores. Toxicity was also comparable, with the exception of an increased incidence of impotence among men who received megestrol acetate.

CONCLUSION

In the doses and schedules we studied, megestrol acetate provided superior anorexia palliation among advanced cancer patients compared with dronabinol alone. Combination therapy did not appear to confer additional benefit.